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Cardiac Heart SoundsHeart SoundLoudSoftSplitS1 (mitral and triscupid closing)Widely open at beginning of systole Mitral stenosis Tricuspid stenosisShort diastolic filling time Pre-excitation TachycardiaMitral regurgDelayed systole LBBBLong diastolic filling time 1st deg HBMI (poor contractility)RBBB (as one venticule commences systole later than another)S2 (aortic and pulmonary closing)HTNCongenital aortic stenosisPulmonary component loud in pul HTNAortic regurgAortic valve calcificationMI (poor contractility)Normal (LV finishes first)Increased (RV takes even longer) Pul stenosis RBBB VSD (LR shunt) Mitral regurgFixed ASDReversed (LV finishes last) Aortic stenosis LBBB Co-arctation of aortaS3 (tightening of papillary muscles at end of rapid diastolic filling; mid-diastole; Gallop rhythm)LVF / RVF (occurs in 15-20% MI and implies failing myocardium)Aortic regurgMitral regurgVSDPDAS4 (reflected atrial wave from stiff LV; late diastole)Aortic stenosis / pul stenosisAcute mitral regurgHTN / pul HTNMIValve diseaseMurmurOther findingsCausesAortic stenosisHarsh ejection systolic murmur radiating to neck+ ejection soundJVP: normal unless CCF (maybe prominent a wave)Carotids: slow risingApex beat: forceful + sustainedPalpable systolic thrillS1: OKS2: reverse split (ie. LV slower)S4LVH / strain on ECGCongenital bicuspid valvesDegenerative calcificRheumaticAortic regurgDecrescendo early diastolic murmurMay be systolic murmur too due to large SVWide pulse pressurePeripheral: Quinke’s sign (pulsation of nail bed); Traube’s sign (prominent femoral pulse); Duroziez’s sign (murmurs over femorals); collapsing pulseJVP: normal unless CCFCarotids: Water hammer, Corrigan’s (prominent)Apex: forceful, unsustained, displacedS1: softS2: OKS3LVH / strain on ECGCongenital biscupid valveRheumaticEndocarditis (most common cause of acute insuff)Aortic dissectionHTNMarfan’sVSDSyphilisMitral stenosisLow pitched diastolic murmur + Opening snapMalar flushJVP: OK unless failureCarotids: OKApex: tappingDiastolic thrillS1: loudS2: OKSmall pulse pressureP mitrale, RAD, RV strain on ECGRheumaticCongenitalMitral regurgPan-systolic murmur(late systolic with systolic click if prolapse; worse with Valsalva and standing)Pulse: threadyJVP: OK unless failureCarotids: OKApex: forceful and unsustainedHeaveS1: softS3P mitrale, RAD, LV strain on ECGMitral valve prolapseRheumaticCardiomyopathyPapillary muscle dysfunctionLVFCT diseasesEndocarditisHOCMLate systolic murmur (incr with Valsalva and standing, decr with squatting)Jerky, sharp pulseDouble/triple apex beatProminent a wave on JVPPDAMachinery murmur (harsh systolic murmur if large)If large: Collapsing pulse Wide pulse pressure LVH on ECGASD (PFO) LR shuntMid-systolic murmur (due to incr flow across pul valve); if large, mid-diastolic murmur (due to flow across tricuspid valve)Wide/fixed split S2P pulmonale, RVH, RBBB on ECGCongenital (25% population)VSDPan-systolic murmur; mid-diastolic murmurDisplaced apex beatPalpable thrillECG shows LVH and RVHCongenitalCoarctation of aortaMid-systolic murmurHTNRadio-femoral delay ................
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